The application of flipped learning to a gross anatomy dissection course

We implemented flipped learning for a gross anatomy dissection course and compared its effects on students’ motivation and academic achievement with those of traditional dissection methods. We invited 142 first-year medical students at Chonnam National University Medical School to participate in this study. All participants engaged in traditional dissection methods in the first part of the study and flipped learning in the latter part. Medical students’ motivation to learn anatomy by cadaveric dissection was measured using the ARCS (Attention, Relevance, Confidence, and Satisfaction) model. Thereafter, all students completed a written examination consisting of 96 multiple-choice questions. The students’ mean motivational score regarding attention was significantly higher in association with flipped learning than with traditional learning. However, the students’ mean motivational scores regarding relevance, confidence, and satisfaction were not significantly different between the methods. Additionally, the mean anatomy practice test score was significantly higher in association with flipped learning than with traditional learning. The students’ motivational scores and anatomy practice test scores associated with flipped learning positively correlated with the extent of learning material completion. The students’ responses indicated that flipped learning helped enhance the learning process, improve time management, reduce confusion during practice, and promote independent practice. The application of flipped learning to a cadaveric dissection course increased individual learning motivation, which improved learning activities both in and out of class, as well as academic achievement.


Introduction
The flipped classroom is an educational paradigm that inverts traditional elements of lecture and homework in course design [1,2].It allows students to initially engage with the learning material before class, thus repurposing class time for active learning exercises in small groups, which facilitates a deeper understanding of the subject matter.Flipped learning is attractive to both students and teachers because it provides pre-class self-regulated learning, in-class active learning with peers, ongoing after-class activities, and assessments aligned to achieve the desired objectives [3].Teachers can spend their face-to-face time supporting students in deeper learning processes [4].The flipped classroom is a student-centred learning strategy in which each student is responsible for coming to class with a basic understanding of the material so that he or she can fully participate and engage in class [5].This emphasis on studentcentred active learning fosters students' motivation to acquire knowledge and enhance skills [6].In particular, deliberative practices, such as cadaver dissection, require more attention and engagement in the activities to improve performance [3].The success of flipped learning in cadaveric dissection teaching may depend on students' undertaking substantial independent out-of-class work [7].
Cadaver dissection plays a formative role in the development of professional competence in medical education.It facilitates learning about the human body, as well as confrontingand developing reasoned and compassionate attitudes toward-death and dying [8,9].Dissection helps to build teamwork that requires students to work cooperatively under difficult, emotionally demanding conditions to accomplish their shared goals related to their future profession [10].However, there is an uneven level of participation within a group because some students are still adapting to the stresses of dissection, and some have not prepared well before dissection sessions [11,12].Peer-assisted learning in dissection laboratories is an effective way to encourage student participation and peer group interaction, but the tendency to rely on competent peers often persists [13,14].Ultimately, an individual's attitudes and behaviours are related to motivation [7].Flipped learning in dissection courses has the potential to enhance the development of self-directed learning as a professional attribute, but few studies have investigated the application of flipped learning to dissection practice [12,15].Abeysekera et al. proposed that flipped learning pedagogy can increase students' intrinsic and extrinsic motivation if it creates a sense of competence, autonomy, and relatedness according to self-determination theory [7].Flipped learning allows students to have the autonomy to study material at their own pace before class, actively learn related content for in-class discussion with peers, and determine their competencies through embedded self-assessment [3,7].The benefit of autonomous motivation is positively associated with behavioural persistence, depth of learning, and satisfaction [16].Therefore, flipped learning has been incorporated into existing peer-assisted learning in cadaver dissection to improve individual engagement and learning outcomes.The first half of the dissection practice was conducted using the traditionally implemented peer-assisted learning method, where student tutors who prepared for the dissection in advance helped peers to learn, with the peer tutors reinforcing their own knowledge through the act of teaching.The second half included the addition of a flipped learning method, in which all students studied video-based materials and solved accompanying quizzes prior to the dissection.This study aimed to compare students' motivation, out-of-class work, and academic achievement between traditional peer-assisted learning and flipped learning, as applied to cadaver dissection.The research questions were as follows: 1. Are there any significant differences in students' motivational scores and practice test scores between traditional methods and the flipped learning method?
2. With the flipped learning method, is there any significant variation in students' motivational scores and practice test scores according to the extent of learning material completion?
3. How satisfied would students be with flipped learning in a gross anatomy dissection course?

Study participants and dissection course
We invited 142 first-year medical students at Chonnam National University Medical School to participate in this study.The study was approved by the Chonnam National University Institutional Review Board (IRB No. 1040198-230418-HR-039-02), and all participants consented to the use of their data.The sample consisted of 108 (76.1%) male students and 34 (23.9%)female students.
All participants had completed a course on gross anatomy as part of the standard curriculum.The dissection component consisted of 16 3-h sessions designed to independently address the back, chest, upper limbs, abdomen, pelvis, lower limbs, head, and neck.During the dissection component, an intact cadaver was allocated to each of the 23 groups of students.Of these, four groups were comprised of seven students each, while the remaining 19 groups each had six students.All participants engaged in traditional learning methods in the first part of the study period-encompassing the back, chest, and upper limbs.The flipped learning method was used for the latter part of the course-encompassing the abdomen, pelvis, lower limbs, head, and neck.A traditional peer-assisted teaching and learning strategy for dissection courses was implemented at the study institution in 2012, and this constituted the traditional learning method investigated in this study [13].Of the 23 student groups, four groups took the roles of tutors during the other groups' respective rotations.In other words, twenty-five students in four groups served as tutors, and one or two tutors were assigned to each of the other 19 groups during the dissection course.The roles of students were then switched during subsequent rotations.Tutors dissected intact relevant cadaver parts in advance with the guidance of textbooks and video clips; they could ask questions to faculty members if they faced difficulties.Members of the four tutor groups provided 10-minute explanations of their pre-session dissections to each tutee group before the start of the dissection.These explanations addressed issues, such as important anatomical structures and how to perform specific steps; they also identified the structures that should be carefully manipulated.In the flipped learning method, the dissection course proceeded in the same way as the traditional method; however, before the dissection course, the students were required to study the material covered in individual dissection sessions in advance using e-Anatomy Ⓡ (Panmun Education, Seoul, Korea).This preparation involved engaging with a series of video clips produced by the Korean Society of Anatomy, which included detailed dissection guides.These guides featured explicit learning objectives, the sequence and techniques of dissection, as well as the anatomical structures to be identified for each body part.The video clips ranged in length from 10 to 40 minutes each, and students were given a link to the Learning Management System (LMS) to learn one or two video clips per dissection component.

Data collection
The medical students' motivation to learn anatomy by cadaveric dissection was measured using the ARCS (Attention, Relevance, Confidence, and Satisfaction) model [17].The survey comprises 29 statements, to which students respond using a 5-point Likert scale (5 = very true, 4 = mostly true, 3 = moderately true, 2 = slightly true, 1 = not true).This survey has four categories: Attention (capturing interest and curiosity of learners), Relevance (connecting the instructional content to learner's academic goals), Confidence (helping students establish positive expectancies for success), and Satisfaction (positive feeling about the learning experience).It contains seven items for Attention, eight items for Relevance, seven items for Confidence, and seven items for Satisfaction.Survey questions were modified after a pre-test targeting 15 second-year students who had completed cadaveric dissection.The students were asked to complete the 29-item paper-based survey twice: once after traditional learning and once after flipped learning.The surveys demonstrated high internal consistency with Cronbach's alpha values of 0.861 and 0.867, respectively.During the survey on the flipped learning method, the students also completed a self-administered questionnaire to report individual perceptions of the experience provided by flipped learning.Evaluation of student performance in each dissection component was conducted through group presentations of dissection results and individual reports, which were rated on a 3-point scale (3 = exceeded expectations, 2 = met expectations, 1 = did not meet expectations).Immediately after completing the dissection courses, all students completed a written examination that consisted of 96 multiple-choice questions.

Data analysis
To assess the impact of the teaching methods on student outcomes, we used paired-samples ttests to compare students' motivational scores, anatomy practice presentation and report scores, as well as written exam scores between the traditional and flipped learning methods.After stratifying the extent of completion into quartiles, we used one-way analysis of variance (ANOVA) with Tukey post hoc analysis to test for completion-associated differences in students' motivational scores and anatomy practice test scores related to the flipped learning method.All analyses were performed using SPSS statistics for Windows, version 27 (IBM Corp., Armonk, NY, USA).

Results
The students' mean motivational score for the attention subscale was significantly higher in association with the flipped learning method than with traditional learning.However, the students' mean motivational scores for the relevance, confidence, and satisfaction subscales were not significantly different between the methods.Additionally, the mean anatomy practice test score was significantly higher in association with flipped learning than with traditional learning (Table 1).
Table 2 summarises the ANOVA and Tukey test findings.The ANOVA analysis revealed significant differences in the students' motivational and practice test scores-associated with flipped learning-according to the extent of learning material completion.Tukey post hoc analysis revealed that students' motivational scores were significantly higher among students scoring in the top quartile in terms of completion extent compared with those scoring in the bottom two quartiles.
After undertaking the flipped learning approach, the students stated that, by incorporating visual images before the actual sessions, the method effectively enhanced the learning process, especially in areas where conveying information solely through text is limited.Participants noted that this approach acted as a reliable guide, providing clear instructions on how to approach the sessions, including details like incision sites and direction.The preliminary video-based learning also served as an effective review tool through subsequent quizzes, reinforcing acquired knowledge and aiding retention.Consequently, students reported improved time management and reduced confusion during the dissection sessions.The utilisation of visual aids also facilitated the identification of anatomical structures without the risk of getting lost or causing damage.Another significant advantage was the promotion of independent practice, reducing reliance on practice group tutors.Regarding areas for improvement, the students noted discrepancies between the state or structure of the cadaver shown in the video and the actual cadaver used in dissection sessions.Some professional techniques and practice tools demonstrated in the video differed from the reality of the sessions.Participants also provided mixed feedback regarding the video durations.Some found it challenging to digest the amount of content presented and expressed difficulty with developing a thorough understanding of the vast material.Conversely, some participants expressed the desire to have access to the omitted intermediate process videos, suggesting that it would enhance their learning experience.Additionally, there were technical issues with video playback, resulting in interrupted viewing experiences (Table 3).

Discussion
The present study affirmed the efficacy of flipped learning in medical education, particularly for courses demanding high levels of professional performance from students, such as human gross anatomy dissection.This study revealed that students who used the flipped classroom for cadaveric dissection-based learning demonstrated higher attention scores than students in the traditional classroom.These findings show that relevant multimedia content-for example, images or videos in e-Anatomy Ⓡ -consumed during the pre-class sessions in flipped learning can play an important role in stimulating student attention [3].In terms of a motivational design approach like the ARCS model used in this study [17], online learning content should be aligned with the four dimensions to enhance student motivation and academic achievement [18].Although learning in the flipped classroom may not yield crucial discrepancies in terms of relatedness with students' goals, competence in performance, and satisfaction with achievement, online content facilitated students' interest and curiosity.Hence, to effectively deliver the flipped learning process in medical education, it is important to understand the four key dimensions (e.g., attention, relevance, confidence, and satisfaction) before designing course content.This study also investigated the extent to which completion rates of the e-Anatomy Ⓡ learning materials in the flipped classroom affected students' motivation levels and learning achievement.The analyses showed that students who completed more of the material tended to report higher levels of motivation across the four different dimensions and demonstrated better learning outcomes.These findings appear to be consistent with the findings from Yoon et al.'s study, wherein the self-regulated learning group showed higher video completion rates than the non self-regulated learning group [19].That is, students' rigorous self-regulated learning in the pre-class sessions implies active behavioural engagement (e.g., video completion), which could lead to enhanced academic performance [19].During the COVID-19 pandemic, a nationwide survey in Korea found that medical schools transitioned to exclusively using e-Anatomy Ⓡ videos or adopted a hybrid approach incorporating online e-Anatomy during the semester, followed by hands-on dissection later [20].This shift to a de facto flipped classroom model in the blended learning scenario was associated with superior educational outcomes when compared with the traditional lecture-based approach prior to the pandemic [20].Likewise, in the present study, students would have been more focused on the e-Anatomy Ⓡ videos to facilitate their performance and understanding of critical topics in the anatomy dissection course.Consequently, these findings show that learning through the flipped classroom before an in-person anatomy dissection course could provide students with more autonomy and selfregulated learning opportunities, affecting their motivation and academic achievement.
Additionally, this study affirmed that students' qualitative feedback will be conducive to developing effective flipped learning courses, as flipped learning is multifaceted and can be applied to variations in practice in medical education [21].Among the numerous benefits of flipped learning that students reported, the pre-class sessions including precise instructional videos helped students prepare for dissection sessions, which enabled them to foster confidence and reduce mistakes during in-person anatomy dissection sessions.On the other hand, content quality and technical issues-such as visually contrasting cadaver imagery, lengthy instructional videos, and compatibility issues on mobile devices-may hamper their learning experiences.Quality content and a robust platform are vital for facilitating learner-content interaction, which serves as a cornerstone for further engagement with instructors and peers [22].Therefore, instructors should critically assess and refine content in light of student feedback to ensure it is optimally tailored to stimulate active learning [23].Overall, this study extended the findings of Fleagle et al., who found that pre-class sessions associated with the flipped classroom were useful for retaining knowledge about anatomy and dissection before the in-class anatomy dissection activities [12].This study also argued that qualitative feedback from students should be taken into account to promote their motivation and further enhance learning experiences by ultimately designing and creating coherent flipped learning content for gross anatomy dissection courses [5,21].
Given that flipped learning may become a widely used and powerful learning method, the present study provides crucial insights into how this approach should be designed and incorporated for both students and instructors of human gross anatomy.Importantly, the flipped classroom offers foundational functions for students in the physical classroom when pre-class sessions with computer-mediated instruction are designed effectively [3].As such, to ensure the effectiveness of flipped learning, instructors should exploit the key principles of videobased learning that make learning effective by providing students with new learning opportunities anytime and anywhere [24].Furthermore, the findings of this study contribute to the extension of the relevant literature in which researchers have revealed the impacts of flipped learning incorporating video-based learning on student motivation [25], successful learning experiences [26], and positive student attitudes [27].Although this study emphasised the importance of flipped learning regarding student motivation and learning achievement, we suggest that instructors consider interactivity between tutors and tutees during in-person anatomy dissection sessions.In this sense, students are likely to improve their motivation and learning efficiency because flipped learning affords students with peer support and instructor guidance [18,28].On the basis of the feedback from students, this study will enhance not only the quality of flipped learning but also in-class learning during human gross anatomy courses.
This study had some limitations.One of the main limitations was that this study was conducted in a semi-experimental research setting.If well-designed experimental research is carried out and includes experimental and control groups, the effects of flipped learning can be thoroughly examined.Another limitation was that we could not accurately measure how long the students concentrate although we tried to measure the extent of completion in the flipped learning by computer-generated data, such as log datasets from LMS .A final limitation was that customised instructional tutorials and videos were not available for our students in the gross anatomy dissection course.Faculty should develop instructional videos that are wellsuited to the anatomy curriculum and course objectives based on the four dimensions of the ARCS model.
Throughout this study, we concluded that the application of flipped learning to this dissection course increased individual learning motivation, which improved in-class and out-ofclass learning activities as well as academic achievement.These insights will contribute to designing effective teaching and learning strategies for gross anatomy courses and offer a novel perspective on integrating flipped learning methodologies into dissection practice.It will be necessary to track the effectiveness of flipped learning using quantitative research approaches, such as motivation scores and academic achievement, as well as qualitative research approaches, such as students' responses.

Table 1 . Comparison of students' motivational scores and anatomy practice scores between the traditional method and flipped learning method.
https://doi.org/10.1371/journal.pone.0298067.t001

Table 2 . Differences in students' motivational scores and anatomy practice scores associated with flipped learning according to the extent of completion.
https://doi.org/10.1371/journal.pone.0298067.t002

Table 3 . Students' feedback about the advantages and disadvantages of the flipped learning method.
The content of the video was so vast that it was not possible to apply all of them to actual dissection.' 'In the process of dissecting difficult structures, some processes were omitted.I hope the video will be supplemented.'